Chronic pain of non-malignant origin poses a severe problem not only to individuals who suffer from pain but to society as a whole. Estimates of the monetary cost of medications and other treatments which provide patients, at best, with temporary relief were estimated at $125 billion annually in 1999.1 A 2003 study on lost productive time and cost due to chronic pain conditions in the United States estimated lost productivity annually at $61.2 billion.2 Other monetary costs include lost wage and disability compensation, lost tax revenue, job absenteeism and disruption in the workplace. Additionally, there are indirect costs, including the lost productivity of spouses and other caretakers of chronic pain patients.
Irrespective of the financial burden of inadequately treated chronic pain, the greatest hardship is that experienced by the patients themselves. Schatman3 has suggested that the debate between practitioners regarding the period of time an individual must suffer from pain in order to be labeled “chronic” is actually meaningless; rather, “chronicity” is determined by the widespread dysfunction which the chronic pain sufferer experiences across a wide range of areas of his or her life. These areas of function include not only the physical, but the emotional, social, recreational, vocational, financial, and legal spheres as well. Healing of chronic pain necessitates helping patients regain control of all of these areas of their lives, as their widespread dysfunction is generally more overwhelming than is the nociceptive experience of pain itself. These patients have typically lost their independence and are reliant upon medications and the aid of others—all contributing to the development of behavioral patterns of general passivity.4-7
Unlike purely nociceptive pain, there is often no “cure” for intractable pain of neuropathic or idiopathic origin. Yet, such pain may still often be successfully treated. Numerous meta-analyses and critical reviews8-14 of integrated multidisciplinary chronic pain management programs offer clear evidence that such programs offer these chronic pain patients the greatest opportunity for relief of their suffering and return to functional lifestyles. Frequently, the prior lack of effective “cure” or treatment of such patients are the result of inadequate diagnoses or sufficiently comprehensive therapeutic approaches. Many times, such clinical epiphanies occur in multidisciplinary settings at which point more effective treatment subsequently occurs. In addition to supporting their clinical efficacy, meta-analyses and reviews8-14 have all supported the cost-efficiency of multidisciplinary chronic pain management programs. In a review by Turk in 2002,13 multidisciplinary chronic pain management was determined to be superior to singular treatments including surgery, pharmacologic intervention, spinal stimulators and intrathecal opioid pumps, in terms of pain reduction, improved physical functioning, and returning patients to the workforce. It is also important to recognize that these unimodal treatment options are often associated with iatrogenic complications and adverse events, which is certainly not true of multidisciplinary chronic pain management programs. In terms of longevity of benefits of integrated multidisciplinary programs, a follow-up study of patients 13 years following treatment was supportive of maintenance of gains.15 Furthermore, multidisciplinary treatment of chronic pain has been associated with reduced utilization of medical services compared to chronic pain patients treated through other approaches, even in countries with national health insurance.16
Despite the body of literature8-16 supporting the clinical efficacy and cost-efficiency of integrated multidisciplinary chronic pain management programs, the number of such programs in the United States is decreasing steadily. According to the Committee for the Accreditation of Rehabilitation Facilities (CARF),17 the number of accredited interdisciplinary chronic pain management programs in the United States has decreased from 210 in 1998 to only 84 in 2005. A similar, although less dramatic decline has been reported by Marketdata Research,18 which looked at the number of programs accredited by either the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the American Academy of Pain Management (AAPM), or CARF. The public is likely unaware of the decreasing availability of multidisciplinary chronic pain management, as many were previously unaware of its existence. Additionally, disinformation regarding the treatment of pain is likely to contribute to the public’s incomprehension of the decreasing availability of interdisciplinary chronic pain management. Recent public awareness campaigns regarding JCAHO’s declaration that pain will now be considered a “fifth vital sign” and the declaration of this being the “Decade of Pain Control” by Congress erroneously suggests that effective treatment of chronic pain of non-malignant origin is becoming a priority of society. These proclamations are certainly inconsistent with the data that has been presented by CARF17 and Marketdata Research.18 What could be the cause of the progressive decline in programs which clearly provide the best treatment option to so many patients who suffer from chronic pain?
Few who dedicate their professional lives to the treatment of chronic pain patients would argue that this is not a difficult population with which to work. Dealing with chronic pain sufferers’ maladaptive emotional and behavioral responses to their physical discomfort makes their treatment extremely complex, and can certainly be emotionally draining for the practitioner. In a presentation, Dr. John Bonica was referred to as the “world champion of pain.”19 Given his personal and professional dedication to the amelioration of suffering, this title was appropriately bestowed upon him. Certainly, all practitioners who work with chronic pain patients need to be “champions of pain” if they are to be effective. Chronic pain practitioners function under the ethical standards of their professions, whether it is medicine, nursing, psychology, physical and occupational therapy, biofeedback, or any other profession which is represented on a multidisciplinary treatment team. Additionally, organizations such as the American Academy of Pain Management,20 the American Academy of Pain Medicine,21 and the American Pain Society,22 to which many pain practitioners belong, each has a code of ethics. All of these codes place an emphasis on the well-being of the pain patient, and one would assume that the vast majority of chronic pain practitioners make an effort to function ethically as well as striving to be effective as clinicians.
Unfortunately, these professionals are not the only people involved in the care of the chronic pain patient. Chronic pain management is not solely the domain of the medical community, but is also impacted by the insurance industry, hospital administrations, the legal system, the pharmaceutical and implantable medical device industries, and a number of other entities. Perhaps the groups most likely to impact a patient’s potential admission into an integrated multidisciplinary chronic pain management program are third party payers and hospital administrators. It is a fact that, given the ethical premise and ethos of these enterprises as business-oriented entities, the attendant actions of these actors may not be wholly consistent with the ends and means of right and morally sound patient care.23 Yet these enterprises have established written and meaningful commitments to domains of patient care, albeit within the constraints of a business environment.
Sadly, while chronic pain management practitioners function under ethical codes of conduct which emphasize the primacy of the patient’s well-being, the business ethos and ethics of the healthcare insurance and hospital corporations may not be directly compatible or supportive of such ethically sound medical care of the chronic pain patient. The effects of such a business-oriented ethos have been infused in the healthcare system and have led to an increasing commodification of medical care. This may be partly responsible for financially-driven motives to reduce or eliminate multidisciplinary pain care as “surplus provision” and, in so doing, render numerous patients without access to such empirically effective care.
Due to its emphasis on the economic model, insurance carriers are reluctant to fund integrated multidisciplinary chronic pain management services. The explanation for this increasingly frequent refusal is multi-causal, and several speculations can be made. First, as third party payers are often “penny wise and pound foolish”, the “sticker shock” of a 4-6 week intensive treatment program often results in their refusal to recognize the formidable body of research mentioned earlier8-16 supporting not only clinical efficacy but cost-efficiency. Second, third party payers often expect multidisciplinary chronic pain management programs to be successful in every case. Stieg noted, “…there is a tendency of third-party payers to expect pain treatment centers to solve all of their patients’ social problems.”24 It is apparent that health insurance carriers do not recognize that even the best multidisciplinary programs cannot control all patient and social variables, and accordingly cannot control all outcomes. Third, multidisciplinary chronic pain management programs sometimes find themselves in competition with pharmaceutical companies marketing medications including opioids, NSAID’s and anti-convulsants as relatively inexpensive “quick fixes” to third party payers. Health insurance carriers may now be even more likely to see medications as an appealing option given the recent switch to generic status of formerly expensive medications such as time-released oxycodone, transdermal fentanyl, and gabapentin, irrespective of empirical findings that suggest that the integration of pharmacological approaches to multidisciplinary care is superior.13 The pharmaceutical approach, alone, is often insufficient to treat the multiple and compound issues that instigate and perpetuate a particular patient’s pain. Finally, as reimbursement for actually spending time with patients are decreasing while reimbursements for procedures are increasing,25-27 there is a developing disincentive for interventional pain management specialists to refer their refractory patients to multidisciplinary chronic pain management programs. Chapman noted that, “Concurrent with the decline in intensive programs is the rise of procedural interventions and medication, which receive a great deal of support from medical technology and pharmaceutical companies”28 Such interventions, while effective in the short term, may not provide lasting relief from pain, and are very often best employed to interrupt the pain-disability cycle so as to make the patient more amenable and capable for other treatment approaches such as biomechanical retraining, occupational therapy, etc.
“One of the most prominent theories in medical ethics is that of principle-based ethics...which suggests that clinical decisions and acts be guided by the mid-level principles of autonomy, nonmaleficence, beneficence and justice.”
While third party payers have become progressively less amenable to funding multidisciplinary chronic pain management programs, hospitals have chosen to terminate them, resulting in reduced availability.17 These programs, while clinically effective, are quite labor-intensive. Due to the disruption which chronic pain patients experience in so many areas of their lives, a wide variety of professionals is required in order to restore them to functional status. A review of the literature fails to yield any studies of the lack of profitability of multidisciplinary chronic pain management programs. Nevertheless, it is evident that these programs are not “cash cows,” and accordingly hospital administrations do not consider them to be consistent with their goals of cost-containment and profit generation.
Based upon the information which has been provided in this article up to this point, a strong argument can be made that the dissipating funding and availability of integrated multidisciplinary chronic pain management programs is the result of conflicts in the ethos and ethics of the business enterprise of health insurance carriers and hospital administrations—despite well-documented clinical efficacy and cost-efficiency.8-14 In order to strengthen this argument, this analysis will now turn to an examination of the progressive demise of multidisciplinary chronic pain management programs within the context of two highly regarded theories of bioethics, each of which is intended to serve as a guideline according to which practitioners can treat patients effectively and ethically.
One of the most prominent theories in medical ethics is that of principle-based ethics proposed by Beauchamp and Childress,29 which suggests that clinical decisions and acts be guided by the mid-level principles of autonomy, nonmaleficence, beneficence and justice. Autonomy refers to the importance of respecting the wishes of the patient regarding the type of treatment which he or she receives (or does not receive). Nonmaleficence refers to the duty of the practitioner to avoid causing harm to a patient, whether it is done intentionally or inadvertently. Beneficence refers to a practitioner’s duty to enhance a patient’s comfort, health and well-being. Finally, the principle of justice (primarily localized to the domain of distributive justice) maintains that the provision of medical services is to be based upon need. Chronic pain management specialists are bound to make an effort to base their treatment of patients upon these four principles. Does this hold true for the other entities which are such powerful determinants of the care which chronic pain sufferers receive?
The bioethical issue of autonomy is a very complex one, and per se is beyond the scope of this manuscript. Used more narrowly, however, the concept of autonomy is important as it applies to problems which patients with chronic pain experience in their efforts to receive the best possible treatment. Multidisciplinary chronic pain management programs place a heavy emphasis on restoring independence to their patients. Generally, decisions regarding their well-being are being made by physicians, allied health care providers, their families, attorneys, and, of course, third party payers. If a health insurance carrier rejects a patient’s efforts to receive multidisciplinary chronic pain treatment, the likelihood of the patient regaining control over his or her life is limited. There is great irony in the chronic pain patient lacking the autonomy to choose the treatment which is most likely to restore his or her independence. Similarly, hospital administrations’ decisions to discontinue clinically-effective multidisciplinary programs limit their availability and, accordingly, chronic pain patients’ autonomy to choose the most effective treatment, and may limit their power to refuse whatever treatments are offered in place of the most effective care.
“Chronic pain management professionals maintain beneficence as a primary goal of their practices in choosing to work with a population which many in the medical field make an effort to avoid.”
Chronic pain professionals are expected to respect the biomedical ethic of nonmaleficence, which dates back to the Hippocratic dictum of “at least do no harm.” Pellegrino and Thomasma30 have noted that physicians need to protect their personal values which shape their practices against external forces inconsistent with their own convictions. The business-oriented, for-profit model, under which third party payers and hospital administrations are constrained to operate, are generally in conflict with the professional model under which chronic pain practitioners function. Insurance carriers and hospital administrations function under the business ethos, the telos of which is profit, which is inconsistent with physicians’ obligation to help ameliorate suffering. Chronic pain management providers often respond to denials for coverage by third party payers by citing or providing them with the aforementioned meta-analyses and reviews which support multidisciplinary treatment, but often to no avail. As hospitals may often function under the dictum of “no profit, no program,” the number of facilities for the effective treatment of chronic pain conditions continues to rapidly decline.17 By ignoring the demonstrable fact that integrated multidisciplinary chronic pain management programs provide effective and cost-efficient care, the business ethos of the insurance and hospital industries, if not maleficent, is certainly tantamount to malfeasance.
Chronic pain management professionals maintain beneficence as a primary goal of their practices in choosing to work with a population which many in the medical field make an effort to avoid. Altruism is closely related to beneficence, and it is the domain of the chronic pain practitioner. Again, the economic model causes problems for multidisciplinary chronic pain management. Pellegrino has stated, “The market ethos does not per se foreclose altruism, yet neither does it impose a moral duty to help…”31 Beneficence by the insurance and hospital industries would be evident if they took steps to promote what has clinically been described as the “gold standard.”32
Justice is perhaps the most difficult of the fundamental bioethical principles to which chronic pain practitioners make an effort to comply. In a very encouraging study in 2001, however, pain practitioners reported that the undertreatment of vulnerable populations was their primary ethical concern.33 Research has suggested that most physicians are committed to providing some services to patients on a reduced fee or pro bono basis, and one would assume that this is also true of chronic pain management providers. However, it would be unfair to expect chronic pain management specialists to not be compensated at all for their time, efforts and expertise. Most integrated multidisciplinary programs in the United States are housed in hospitals,17 with their administrations playing the role of gate keeper and deciding who will receive treatment. While a review of the literature does not yield any studies on the extent to which hospitals are willing to treat chronic pain patients on a reduced fee or pro bono basis, the well-documented dual health care system in this country would suggest that patients with chronic pain are likely to be eligible for treatment in integrated multidisciplinary clinics based upon the quality of their third party coverage.
While Sullivan34 has argued for the superiority of principle-based ethical theories, they offer little to practitioners in terms of guiding behavior in order to positively impact the diminishing role of the multidisciplinary chronic pain management programs. Yet the commodification of the health care system in this country has rendered patients “consumers” who are exposed to a system of cost-containment in commodity development and supply-restricted, demand-side provision.35 Accordingly, patients not served by this standard of care are allowed to remain in pain and to suffer when the ability to remedy these experiences exists. This situation has been referred to as a “serious breach of fundamental human rights.”32
Virtue ethics suggests that the virtuous individual is disposed to act in accord with the virtue appropriate to the situation, somewhat de-emphasizing principles and rules.33,36 In any healing profession, including chronic pain management, it is essential that the “ends” of the clinical relationship be the well-being of the patient, which physicians are morally obligated to pursue.37 An emphasis needs to be placed on protecting the dignity of the patient, with the self-interest of the practitioner suppressed.36 Giordano37 has argued that the unique aspects of chronic pain and the nature of pain-based clinical practice demand that pain management professionals serve as moral agents as well as therapeutic agents for our patients, and is consistent with the aforementioned necessity of serving as “champions of pain.” Serving as advocates is the most obvious and perhaps effective way in which physicians can champion for the powerless and disenfranchised pain patients and, in so doing, allows physicians to function as their moral agents.
The question remains, however, how far should physicians go as champions of pain in efforts to advocate for patients? Some bioethicists34,38 have suggested that clinicians should make all and any efforts to help reduce patients’ pain and suffering. As advocates for chronic pain patients who are trapped in the cross-fire of ethical systems and ethos of practices, perhaps physicians should do everything medically necessary to help patients. In a discussion of law and ethics, Pellegrino noted that “Physicians have an obligation to advocate the patient’s cause whenever it is threatened by a harmful rule or policy.”39 The rules and policies of the insurance and hospital industries are clearly harmful to chronic pain patients, perpetuating their pain and suffering by progressively disallowing access to the best possible treatment. However, Pellegrino39 offered caution, warning that “gaming” insurance companies through deception (e.g. exaggeration of a patient’s symptoms) in order to gain third party coverage is not morally defensible. While some champions of pain patients may be willing to bend the rules in order to help patients who have become quagmired in a hopeless situation, other bioethicists40,41 argue that physicians are obligated to adhere to professional stands, the laws of jurisdiction, and the rules of the institutions that fund and provide health care. There is no definitive answer to the question of how aggressive physicians should be, as champions of pain, in efforts to advocate for patients and for the programs that treat them most effectively. Virtue ethics suggests that physicians should exercise beneficence which surpasses passive nonmaleficence, even if it puts one at personal risk.30 Yet as there are so few clinicians and so many chronic pain patients, one can only advocate aggressively for a small percentage of the patients who need help. Another answer, consistent with principle-based ethics and virtue ethics, is needed.
The marketplace economy does not function particularly well in the provision of certain fundamental human rights, including access to effective management of chronic pain of non-malignant origin. Pellegrino has called for a “mixed economy” in response to the commodification of medicine, stating that “…freedom from acute or chronic pain, disability, or disease, is a condition of human flourishing. Human beings cannot attain their fullest potential without some significant measure of health. A good society is one in which each citizen is able to flourish, grow, and develop as a human being.”31 While it is beyond the scope of this article to call for socialized medicine, it is clear that the government must become involved in the development, funding and management of multidisciplinary chronic pain management services in order to meet its moral obligation to society. Justice must be served by providing adequate care to all who require it. Given the staggering financial cost of inadequately treated chronic pain discussed earlier in this article, along with needless suffering of millions of individuals with chronic pain, the government is obligated to exercise what has been referred to as “beneficent justice.”31 Pellegrino defined beneficent justice as “justice ordered by the obligation to rescue, sustain, and nourish both society and the individual, since each suffers if either is neglected or abused.”31
Governmental development, funding and management of multidisciplinary chronic pain management centers would not be unprecedented, as its development of the Medicare and Medicaid programs was originally an effort to do the right thing, i.e. to take responsibility for the medical needs of people who are disempowered and disenfranchised to the extent that they would not receive medical care without the government providing them with a means of accessing it. Government-subsidized multidisciplinary chronic pain management centers should provide training opportunities for clinicians, as well as treating patients who are in need. Most of the few high-quality multidisciplinary programs still in existence offer fellowship opportunities, although the progressive decrease in the number of programs in this country causes one to wonder where these fellowship-trained specialists will work. Additionally, these federally funded and managed clinics should provide opportunities for research, as doing so will enhance the discipline’s evidence basis and overall effectiveness and cost-efficiency. While one may argue that the start-up costs of such clinics would be high, the overwhelming cost of inadequately treated chronic pain to society and individuals would make their development an investment in the financial well-being of our country as well as meeting the government’s moral obligation to ameliorate suffering.
In March of 2005, the National Pain Care Policy Act (H.R. 1020) was introduced, calling for the consideration of adequate treatment, education and research relating to pain management as national public health priorities.42 One of the bill’s provisions is for the development of six regional pain treatment and research centers. This legislation represents only a first step toward remedying the crisis of limited access to adequate chronic pain management services in this country, as many more than six such centers are needed. At the rate at which Congress moves on this type of legislation, the possibility exists that six or more of the multidisciplinary programs currently operating will be forced to close prior to the development of the facilities specified by H.R. 1020. In a recent newsletter, American Pain Society President Dr. Dennis Turk urged pain specialists to engage in grassroots lobbying in order to gain cosponsors for this legislation.43 Doing so is of critical importance, as the extent to which we can realistically “champion” for individual patients is limited by the ethical and legal standards of our professions. In order to act ethically, those of us who understand the importance of integrated multidisciplinary chronic pain management are obligated to represent the continued existence of the best approach to chronic pain as well as to help our patients on an individual basis. It is important to note that the disciplines involved in multidisciplinary chronic pain management, including medicine,44-47 nursing,48-51 psychology,52-55 physical therapy,56 occupational therapy,57 and biofeedback58 have each made strong calls for obligatory social and political activism in order to help their patients.
The efficacy and cost-efficiency of integrated multidisciplinary chronic pain management have been well established. Unfortunately, statistics indicate that the number of programs in this country providing such services is rapidly declining. While health care professionals are bound by ethical standards, the differing business ethics among third party payers and hospital administrators is resulting in the progressive demise of the programs which can so effectively treat patients who suffer from chronic pain of non-malignant origin. Principle-based ethics and virtue ethics support the expanding need for multidisciplinary chronic pain management within the healthcare system despite the business-oriented decisions to the contrary. Accordingly, strong government intervention is imperative. Given the tremendous financial burden to society caused by inadequately treated chronic pain along with the moral obligation of the government to ameliorate the needless suffering of so many of its citizens, the development of a sufficient number of high-quality, government funded and managed multidisciplinary chronic pain management programs may offer the discipline and patients their only hope. As ethical pain management professionals, we are obligated to participate in grassroots efforts in order to facilitate the process whereby the government assists in taking some responsibility for the pain and suffering of its citizens.